NAC616C.073. Claims: Forms; filing; electronic transmission.

     1. A claim for compensation must be printed or typed, properly titled, signed and dated by the person filing the claim or the person’s attorney or other representative. A claim for compensation that is filed by electronic transmission must be signed with an electronic symbol representing the signature of the person submitting the claim that is:

     (a) Unique to the person who uses it as a signature;

     (b) Capable of verification; and

     (c) Linked to data in such a manner that the signature is invalidated if the data is altered.

     2. A report of injury must be submitted on a form prescribed by the Administrator and provided by the insurer or third-party administrator. The form must set forth the name and address of the injured employee and the time, place, nature and cause of the injury. If the employer files the report of injury by electronic transmission, the employer must retain the original report for 3 years, unless, pursuant to NRS 616C.045, the insurer or third-party administrator requests the employer return by mail the report that contains the original signature of the employer or the employer’s designee.

     3. The original of each claim for compensation that is filed by electronic transmission must be retained by the physician or chiropractor who initially examined the injured employee for 3 years, unless, pursuant to NRS 616C.040, the insurer or third-party administrator requests that physician or chiropractor to return by mail the claim for compensation that contains the original signatures of the injured employee and the physician or chiropractor.

     4. If the injury or occupational disease will result in the injured employee losing time from work and the injured employee has been reporting his or her income from tips, the employer shall submit the amount of tips declared on Form D-23, which must be included in calculating the average monthly wage of the injured employee pursuant to NRS 616B.227.

     [Industrial Comm’n, Nos. 4.011 & 4.021, eff. 6-30-82]—(NAC A by Div. of Industrial Insurance Regulation, 2-22-88; A by Div. of Industrial Relations, 3-28-94; R098-98, 12-18-98)